Volume 7
Issue 1
Jan-Mar 2013
Contents } Coracoid bone graft osteolysis after Latarjet procedure: A comparison study
between two screws standard technique vs mini-plate fixation } A biomechanical assessment of superior shoulder translation after reconstruction
of anterior glenoid bone defects: The Latarjet procedure versus allograft reconstruction } Beyond the peak of the anterior glenoid rim: A cadaveric study } Ossification of the suprascapular ligament: A risk factor for suprascapular nerve
compression? } Digital photography for assessment of shoulder range of motion: A novel clinical
and research tool } Supraspinatus and infraspinatus compartment syndrome following scapular
fracture } Arthroscopic autograft reconstruction of the inferior glenohumeral ligament:
Exploration of technical feasibility in cadaveric shoulder specimens } Metal markers for radiographic visualization of rotator cuff margins: A new
technique for radiographic assessment of cuff repair integrity
Editors Joe F. de Beer and Deepak N. Bhatia. Printed and published by Medknow Publications and Media Pvt. Ltd. on behalf of Cape Shoulder Institute, Cape Town, South Africa and Printed at Dhote Offset Technokrafts Pvt. Ltd., Jogeshwari, Mumbai, India and published at B5-12, Kanara Business Centre, Ghatkopar, Mumbai, India.
Case Report
Access this article online Website: www.internationalshoulderjournal.org
Supraspinatus and infraspinatus compartment syndrome following scapular fracture
DOI: 10.4103/0973-6042.109891 Quick Response Code:
Ryan M. Kenny, Christopher W. Beiser, Arun Patel
ABSTRACT Acute compartment syndrome occurs when pressure within a confined fascial space rises to a level impairing microvascular perfusion to surrounding tissues.[1‑7] The majority of the reported literature is based on lower extremity compartment syndrome, but any muscle group within an osteofascial compartment has the potential to develop compartment syndrome. We report a case of a 64‑year‑old male who developed an acute compartment syndrome of both the supraspinatus and infraspinatus after sustaining a severely comminuted scapula fracture. Diagnosis of compartment syndrome was made after intracompartmental pressure measurements of the supraspinatus and infraspinatus revealed pressures within 30 mmHg of the diastolic blood pressure, prompting emergency decompressive fasciotomy. At final follow‑up, the examination revealed full shoulder strength with near‑full range of motion. There were no signs of sequelae from compartment syndrome at any point. Few case reports describe compartment syndrome of the periscapular fascial compartments. However, these cases were either retrospectively diagnosed[8,9] or diagnosed via magnetic resonance imaging (MRI) findings and lab values.[9,10] Surgical management of acute compartment syndrome of the supraspinatus has been reported in only one other case.[10] To our knowledge, we report the only case of a patient with acute compartment syndrome of both the supraspinatus and infraspinatus compartments treated with emergent decompressive fasciotomy. Due to the devastating complications and functional loss of a missed diagnosis of compartment syndrome, a high index of clinical suspicion for developing compartment syndrome must be maintained in every fracture setting, regardless of anatomic location or rarity of reported cases.
Department of Orthopedics, Mercy St. Vincent Medical Center, Toledo, OH, USA Address for correspondence: Dr. Ryan M. Kenny, 10270, Desmond Place, Perrysburg OH, USA. E‑mail:
[email protected]
Key words: Supraspinatus, infraspinatus, compartment syndrome, scapula fracture
INTRODUCTION Compartment syndrome has been defined as any condition in which pressure build‑up within closed osteofascial space compromises tissue circulation and function.[1‑7] The resultant ischemia can quickly cause irreversible muscle and nerve damage leading to musculotendinous contractures and sensorimotor deficits.[7] Urgent diagnosis and surgical treatment with decompressive fasciotomy is the key to optimizing functional outcome.[1,5,8] Diagnosis of compartment syndrome heavily depends on clinical presentation and becomes increasingly difficult in patients who are unconscious,
intoxicated, or have altered mental status. Measurement of compartmental pressures using various devices has been shown to help facilitate diagnosis in such patients.[2,4] Compartment syndrome of the upper extremity has been extensively described and reported in the hand, forearm, and upper arm, with the forearm most commonly affected.[8‑11] A literature review returned only 4 other case reports termed compartment syndrome of the periscapular fascial compartments of the supraspinatus or infraspinatus.[12-14] Some authors suggest that the rarity of upper extremity and shoulder region compartment syndrome may be due to
Please cite this article as: Kenny RM, Beiser CW, Patel A. Supraspinatus and infraspinatus compartment syndrome following scapular fracture. Int J Shoulder Surg 2013;7:28-31.
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Kenny, et al.: Scapula fracture compartment syndrome
the blending of fascial communications seen between the infraspinatus, deltoid, pectoralis, and brachial fascia, which may help to dissipate pressure build‑up.[9‑11] To our knowledge, we report the only case of a patient with a comminuted scapular fracture that developed an acute compartment syndrome of both the supraspinatus and infraspinatus, diagnosed via intracompartmental pressure measurements and treated with emergent decompressive fasciotomy.
CASE REPORT A 64‑year‑old male involved in a motor vehicle collision presented with left shoulder and facial pain. Examination revealed a swollen, soft shoulder [Figure 1] with scapular and acromioclavicular (AC) joint tenderness and painful motion. X‑rays showed a comminuted scapular body and spine fracture extending to acromion base with AC joint widening [Figures 2a, b and 3]. The patient’s airway later became compromised secondary to facial fracture swelling, requiring intubation.
Figure 1: Posterior view of left shoulder showing extensive swelling, ecchymosis, and abrasion
Later, evaluation revealed increased swelling and tenseness over the left scapula. Supraspinatus and infraspinatus compartment pressures were measured at 49 mmHg and 32 mmHg, respectively, with a diastolic blood pressure of 43 mmHg. Fifteen hours after presentation, emergent fasciotomy was performed. The incision extended over the scapular spine similar to a modified Judet incision.[15,16] Upon release, the supraspinatus and infraspinatus compartments showed good muscle escape, beefy red coloration, adequate bleeding, and contracture with stimulation [Figure 4]. Elevated serum myoglobin levels prior to fasciotomy were 2705 ng/ml, which declined to 1221 ng/ml and 630 ng/ml on postoperative day #1 and #2, respectively. The combination of scapular spine, acromion base, and AC joint separation prompted plans for open reduction internal fixation (ORIF),[17] which were delayed until hospital day #13 due to pneumonia [Figure 5]. Twenty‑week post‑op examination revealed active shoulder motion of 50° requiring removal of the AC plate and manipulation under anesthesia. Final 10‑month follow‑up revealed full strength and near‑full flexion and abduction with complete radiographic bony healing. There were no signs of sequelae from compartment syndrome at any point.
a
b
Figure 2: (a and b) AP and Lateral plain radiographs of Left shoulder injury demonstrating AC joint widening, acromion base fracture, scapular spine and body fracture
DISCUSSION
Figure 3: 3D reconstruction CT scan of left scapula showing segmental fracture of scapular spine and extensive comminution of scapular body
To our knowledge, we report the only case of a patient with a comminuted scapular fracture that developed an acute compartment syndrome of both the supraspinatus and infraspinatus, diagnosed via intracompartmental pressure measurements and treated with emergent decompressive fasciotomy. The diagnosis of compartment syndrome is frequently a clinical diagnosis based primarily on findings of
pain out of proportion and pain on passive stretch of involved muscles.[1‑7] The unconscious or obtunded patient at risk of compartment syndrome presents a difficult challenge for the physician in that these findings are either unreliable or unobtainable. The use of additional diagnostic modalities of intracompartmental pressure monitors has been found to be useful in such patients.[2,4,6] The unfamiliarity and rarity of
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Kenny, et al.: Scapula fracture compartment syndrome
studies and its acceptance has diminished.[6,18,19] Prayson et al. challenged accepted thresholds and formulations for diagnosing compartment syndrome.[19] Their study measured compartment pressures in 19 lower extremity fractures, all lacking clinical signs of compartment syndrome. Ninety‑five percent of patients had at least one compartment measurement >30 mmHg and 84% had measurements within 30 mmHg of diastolic pressure. No patient developed sequelae for untreated compartment syndrome. To our knowledge, there is no similar study to that of Prayson et al. involving baseline upper extremity fracture compartment measurements. Further study may be useful to help guide treatment and evaluate injury location as a possible variable in the development of compartment syndrome. Figure 4: Intraoperative view after fascial release of the infraspinatus and supraspinatus
Figure 5: Postoperative AP shoulder plain radiograph after scapular spine and AC joint fixation
reported scapular compartment syndrome requires adherence to thorough physical examination, a high index of suspicion, and when necessary, the utilization of compartment pressure monitoring to prevent missed diagnosis. In 1992, Landi et al. reported the first two cases of scapular compartment syndrome.[12] The first case described a patient with extensive necrosis of the infraspinatus encountered during exploration of a non‑healing pressure ulcer. The authors attributed this finding to possible ischemia from unrecognized compartment syndrome. The second case described a patient with a scapular fracture with increasing pain and swelling. Intracompartmental pressure measurements revealed an absolute pressure of 75 mmHg, which continued to decline on subsequent measurements. Fasciotomy was cancelled due to dissipating pressures and resolving symptoms. Follow‑up demonstrated full motion, and absence of pain with no sequelae of an untreated compartment syndrome. The diagnosis of compartment syndrome based on absolute pressure measurements alone has been challenged in several ♦ International Journal of Shoulder Surgery - Jan-Mar 2013 / Vol 7 / Issue 1 30
Compartment syndrome is not only the result of an increased volume within a fixed space, but rather the body’s inability to compensate for a change in the microvascular pressure gradient within a compartment. Once pressures have exceeded capillary perfusion pressure, the ability to exchange oxygen and clear waste is hindered. The resolving clinical signs and lack of sequelae despite the elevated compartmental pressures as seen in Landi et al.’s case further substantiates that compartment syndrome is not purely related to an increase in volume but involves other confounding variables. The relationship between the measured compartmental pressure and diastolic pressure gives a more accurate insight into the dynamic compartmental environment. This pressure differential value, as originally described by Whiteside et al.[6] as significant when absolute pressure measurement is within 30 mmHg of the diastolic pressure, has become more widely accepted as the diagnostic criterion compared to the use of an absolute pressure alone. As seen in our case, patients with hypotension have lower intravascular pressures and may have inadequate tissue perfusion even at mild increases in intracompartmental pressure. [2,6,7] A normotensive or hypertensive state in our patient may have been protective against rising compartment pressures. Stahlfeld et al.[14] described a patient with severe shoulder pain that failed to respond to analgesics. The patient denied any history of trauma, but admitted intensive upper extremity weight lifting prior to a plane flight. Diagnosis of compartment syndrome was made based on magnetic resonance imaging (MRI) findings of an enlarged and edematous supraspinatus. Fasciotomy was performed with hypercontracted and necrotic myofibers shown on biopsy. EMG 15 months after insult demonstrated persistent injury to the supraspinatus with shoulder abduction limited to
